Program Eligibility Questionnaire (PEQ)

Thank you for taking a few minutes to answer this short questionnaire. The information you provide will help us determine if you may qualify for a monthly share credit based on your participation in any financial assistance programs that may be available. Please complete this form within the next 15 days so that we can continue processing your bill(s) for sharing.

Because Medi-Share is a not-for-profit healthcare sharing ministry, not insurance, it’s important that we are good stewards of resources, especially member sharing dollars.

Over $110 million dollars have been saved since 2009 because of member participation in assistance programs.
These savings add up to approximately $100 dollars per household per month, which helps keep members’ monthly share amounts affordable.

If you do qualify for a program and choose to use it, you will receive a share credit of 10% of the total eligible medical bills paid by the program. (Medi-Share Guidelines Section VI. M.)

Participating in programs is voluntary. It is not required that you participate in an assistance program, even if you are eligible for the program. Thank you for completing this questionnaire so we can continue processing your bill(s).

Your Personal Information:

Date: * * Completed By: Membership #: Name of Head of Household:

State: Phone: Email: Name of Patient: Patient Date of Birth: * Effective Date (on membership card): *

Medical condition: First date of service: * Is this condition? Maternity Other
Estimated Date of Delivery:

Your Family Information:

What is your family’s approximate annual gross income: $
How many dependent children under 18 are living at home (Please include unborn child(ren) if a maternity)?
Is the sum of your cash, checking, savings, IRA’s, or life insurance cash value greater than $6,000?

Have you experienced a significant change in income during the last 6 months?
If YES, what was your gross income for the last 3 months (total of all 3 months)?

Have you or your immediate family members ever participated in a special program such as Medicaid, Medicare, WIC or any type of benevolent programs?
If YES, specify:

HEAD OF HOUSEHOLD (or patient 18 years or older)

Occupation (if you are self-employed, please list the nature of your business):
As the Head of Household (if applicable) are you currently unemployed (due to hardship/medical condition)?

Are you a veteran?

SPOUSE (IF APPLICABLE)

Occupation (if you are self-employed, please list the nature of your business):
As the Spouse (if applicable) are you currently unemployed (due to hardship/medical condition)?
Are you a veteran?

MIDWIFE VERIFICATION (FOR APPLICABLE MATERNITY)

Estimated Date of Delivery: * Midwife's Name: Midwife's Phone #:

Midwife's Address:

I choose NOT to apply for Programs

By typing my full name in the following field, I certify that I have read and understand the Medi-Share Guidelines regarding Eligibility for Sharing and Members Entitled to Insurance or Other Benefits and that I (and the patient if applicable) continue to qualify for membership in the Medi-Share program under those Guidelines. I also certify that I (and the patient if applicable) continue to profess the statement of faith and am living pursuant to the Christian lifestyle requirements outlined in the Guidelines.

Head of Household name, Spouse, or name of patient 18 years or older * Date * *